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Role of Joint Commission in Enhancing Compliance with Regulatory Requirements Accreditation is an essential tool for enhancing compliance with regulatory requirements. The health care organization will benefit significantly from accreditation, with many benefits attributed to it. Complying with regulatory requirements will ensure that the health care organization improves the quality of care to patients and increase patient satisfaction, which enhances trust between health professionals and patients. Additionally, the hospital will be able to ensure the privacy and protection of patient health information. It will also be able to meet the needs of the stakeholders, which includes serving the community. With this understanding, the summary brief will give an overview of accreditation in health care, state the most common accreditation requirements, compare and contrast accreditation and regulation requirements, and explain how accreditation helps health organizations meet regulatory requirements. Additionally, the summary brief will also analyze essential Joint Commission standards that apply to the organization, outline best practices for meeting accreditation requirements, discuss another accrediting body other than the Joint Commission, and analyze the benefits the health organization could get from its accreditation.
Nursing Expert Writers: Accreditation in Health Care
According to the Accreditation Commission for Health Care (2022), accreditation in health care refers to an official review process of hospitals and other health facilities, which allows them to show their capability to meet official regulatory requirements and standards. The requirements for accreditation differ among the various accrediting bodies in the United States. Still, they all have the same intentions: to ensure that the health care organizations stay committed to meeting their accreditation standards to enhance better performance and effective patient care. High levels of performance and patient care are essential for health care organizations since they improve patient outcomes, patient satisfaction, and job motivation and retention.
Various accrediting bodies in the United States include the Accreditation Commission for Health Care (ACHC), the Center for Improvement in Health Care Quality, and the Joint Commission (TJC). The Centers for Medicare and Medicaid Services (CMS) issues deeming authority to these accrediting bodies for them to ensure that the accredited health care organizations comply with corresponding Medicare regulations (Accreditation Commission for Health Care, 2022). Hence, when an organization like the Joint Commission offers an accreditation certification to a hospital, it implies that the health care organization complies with regulations set by the CMS. According to Wadhwa and Huynh (2021), the Joint Commission is responsible for accrediting over 20,000 health care programs and organizations in the United States, with 70 to 80% of its functions being to address patient safety. The goals of the accrediting body ar to ensure the provision of quality patient care, enhance patient advocacy and prevent patient harm.
While various accrediting bodies benefit a health organization, it is important to consider the costs. This can help the health organizations decide whether to go through the accreditation process or avoid it. Weighing the costs and benefits can also help a hospital plan when to conduct the process. Additionally, it can help in choosing the right accreditation body, with each having different pricing and requirements needed to offer accreditation to the health institution.
Accreditation Requirements Writing Assignment Help
There are various common requirements needed for a health organization to be accredited. One of the requirements is for the hospital to ensure an efficient fire extinguishing system to handle any fire threats in the organization. Another common requirement is to manage risks linked with the hospital’s utility systems. The utility systems in health care organizations include electrical systems, ventilation, refrigeration, and air conditioning. Patients can be put at risk when the systems are not well maintained. For instance, air conditioning is essential to control temperatures, while refrigeration is vital to preserving specific medications. Visit Nursingexpertwriters.com for help.
Another common requirement is to
Another common requirement for accreditation is for staff to be competent in performing their responsibilities. This is an important requirement for the certification of a hospital since health staff is essential in the improvement of performance and provision of quality care. Most health care professionals interact directly with patients, hence the need to be competent in their duties. Additionally, proper planning of patient care is a necessity for official certification. Another common accreditation requirement is for patient records to contain information that reflects the patient’s care and treatments received at the health organization. There should be no errors in the patient records since information about patients is sensitive and needs to be accurate.
Additionally, a hospital needs to implement prevention and control activities. This is necessary for certification to occur since it enhances patient safety by ensuring that the organization prevents risks instead of acting when they happen. Finally, the health organization should offer health care services and treatments per the prescriptions required by law and regulation. For instance, if a particular medication is prohibited to specific patients under a particular age, the hospital should comply with the law and not issue it to restricted people.
Accreditation and Regulatory Compliance
Regulatory regulations are rules that must be followed by a health organization and its stakeholders, while accreditation requirements are those that need to be adhered to for a seal of approval from an accrediting body to be issued to certify that specific standards have been met. For instance, for a health organization to get accreditation from the Joint Commission, it must adhere to particular standards and get a three-year certification award after meeting the requirements (The Joint Commission, 2022). An example of a regulatory requirement is the Health Insurance Portability and Accountability Act (HIPAA), which defines how health organizations should access and manage patient health information. According to Moore and Frye (2019), the HIPAA privacy rule sets the standards that hospitals need to follow to prevent breaches or violations of patient information and regulates the use or disclosure of information. An example of an accreditation requirement is a Joint Commission standard which states that an organization needs to take action when a staff member’s competence does not meet expectations (OSHA, n.d.).
Accreditation can help a health organization meet its regulatory requirements. For instance, the Joint Commission can ensure that a health organization meets its patient safety requirements through accreditation. According to Wadhwa and Huynh (2021), the Joint Commission ensures that hospitals adhere to policies and procedures and conduct unannounced visits to health care organizations. The unannounced visits ensure that hospitals are always prepared for the visits, hence meeting their regulatory requirements. In addition to unannounced visits, the Joint Commission carries out a vigorous process of tracing a patient’s experience when receiving care and evaluating risks and concerns within the organization. This helps the hospital meet regulatory requirements.
Joint Commission Standards Writing Assignment Help
Various Joint Commission standards apply to this organization. Once followed, they can ensure that it improves patient care quality, better protection of patients’ data, and meets the stakeholders’ needs, including the community. One of the Joint Commission’s
is for the hospital to orient health staff on relevant hospital and unit-specific policies and procedures (OSHA, n.d.). This is an essential standard that the organization needs to meet. Staff education on all the policies and procedures of the institution will enhance compliance and reduce incidences that can hinder patient safety.
Another TJC standard is ensuring staff members participate in ongoing education and training to increase competency and document their documentation. For instance, the health care organization can provide ongoing training and education to all staff on compliance with the Health Insurance Portability and Accountability Act (HIPAA). This can ensure that privacy breach incidences are significantly reduced or avoided in the future. Education and training can also share the consequences that the health staff members could get for violating HIPAA, which will enhance caution when handling patient data. Additionally, there must be documentation of participation to ensure that all members attend them and agree to comply with the laws and regulations.
Another essential Joint Commission standard is for the hospital to select and carry out a high-risk process and conduct a proactive risk assessment at least every 18 months (OSHA,n.d.). Proactivity will help improve the health organization and help prevent risks that can harm patients or their information. Risk assessments in various departments can detect areas that need to be addressed promptly to avoid future mistakes that can cost the hospital. A risk assessment of patient health information systems can detect areas that need to be fixed to prevent future privacy breaches.
Additionally, a TJC standard is to ensure that the hospital takes necessary action when a staff member’s competence does not meet the expectations of a health organization. This applies to our health organization, whereby staff members involved in privacy breaches can be given warnings or disciplinary actions. Violating HIPAA laws can be interpreted as a lack of competency since health employees handling patient information are required to understand the laws to avoid facing legal penalties and putting the organization at risk of legal confrontations. Failure to take the necessary action on incompetent workers as required by the Justice Commission can lead to consequences in the future. For instance, a lack of competency in handling patient data can lead to significant breaches, costly to the hospital due to lawsuits and penalty fines.
Another TJC standard that applies to the hospital is reporting and investigating security incidents involving patients, staff, and other stakeholders within the organization based on its processes (OSHA, n.d.). A security incident can entail a privacy breach, which requires the institution to investigate the incident and report it to the relevant authorities. The organization can investigate the cause that led to a security incident, identify the stakeholders involved in it, and final report. For instance, in the case of HIPAA violations, a health institution needs to report the incidences to the Office for Civil Rights (Moore & Frye, 2020). Additionally, the hospital needs to have its processes for investigating incidences.
Accreditation Best Practices
There are various practices that the health organization can take to meet accreditation requirements. One of the practices is to conduct a mock survey. A mock survey is a self-evaluation tool to help the organization see how it best meets TJC requirements. The hospital can evaluate its compliance with the Joint Commission standards through an internal assessment team, preparing it for the actual accreditation inspection. Mock inspection can include ensuring that the hospital has an effective patient care plan and ensuring that staff members are competent in their responsibilities to avoid putting patients at risk of harm. The assessment team can also evaluate the organization’s education and training program to ensure that it increases competency among health care professionals. Moreover, the hospital equipment, such as the fire emergency system and utility systems, can be assessed to ensure they are in good condition to ensure safety in the institution. If found faulty, they can be fixed early and maintained to ensure they remain functional.
Another best practice to ensure the hospital meets accreditation requirements is identifying gaps in compliance. According to the Joint Commission (2022), identifying and documenting areas of improvement can help the organization target its efforts and prioritize its resources to address them. A hospital can identify gaps in care delivery, such as interruptions in care delivery, loss of patient information, and patient breaches. Identifying gaps can enable the hospital to focus its resources on addressing the gaps to ensure that it meets the standards set by the Joint Commission. For instance, a health organization can address cases of privacy breaches by training health staff on compliance with the organizational regulations and HIPAA laws. Additionally, if the organization finds that there is a shortage of nursing staff, leading to an increased risk of harm to patients due to fatigue-related medication errors, it can address the issue by employing additional nurses and reviewing their shifts to ensure they do not overwork. Fixing the health issues early can ensure that the hospital meets the accreditation standards.
Another best practice is creating a timetable for compliance. According to the Joint Commission (2022), after identifying areas of improvement, it is essential to assign dates for completing addressing the gaps. Setting dates to complete targets will enhance competency among the hospital leadership and stakeholders to ensure that THC standards are met. For instance, the health care organization leadership can decide to take measures to improve prevention measures within a certain period and establish metrics to measure their progress.
Additionally, a health care organization can collect information on successful best practices of other hospitals to help evaluate its progress. Many health care organizations are already accredited, and following their best practices can improve hospital standards to meet accreditation levels. According to Wadhwa and Huynh (2021), over 20,000 hospitals are accredited by the Joint Commission. Among the 20,000 health facilities, the hospital requiring accreditation can select one of them and benchmark it. For instance, it can be identified that an accredited hospital has more competent health care workers, better risk prevention measures, and better utility systems, prompting the institution in need of accreditation to learn from it. Finally, the health organization can modify the best practices of other organizations and implement them.
Other Accrediting Organizations
The Accreditation Commission for Health Care (ACHC) is an accrediting organization recognized by the CMS. It can be used as an alternative to the Joint Commission since, despite having different requirements, they all aim to improve performance and patient care. One benefit of the ACHC is that it does not charge for updating accreditation standards. This implies that the hospital can save costs on accreditation renewal. Another benefit is that compliance with ACHC accreditation standards ensures that a healthcare organization enhances its operational efficiency and is better prepared to deliver quality healthcare services (Accreditation Commission for Health Care (2022). Moreover, accreditation with ACHC ensures credibility with the government
Analyzing the costs and benefits of meeting accreditation requirements is essential for the health care organization. If the benefits outweigh the costs, the hospital can consider getting accredited. However, if the costs outweigh the benefits, it could consider avoiding it or postponing it to the future. In my view, the costs and required efforts for meeting accreditation requirements have value to the hospital. The financial costs that the health institution is likely to incur include resources used for training and enhancing readiness for accreditation assessment. If an organization decides to conduct mock surveys to evaluate its compliance with certification standards, identify gaps, and address them, it will use a lot of resources, which can affect its financial performance if it has failed to budget for the activities. Another cost to the organization is the time taken for the health facility to reach the official certification standards. It will take significant time for the health staff members to be briefed on the areas to improve, including training and educating them on the accrediting standards. Additionally, once organizational gaps are identified, they will require time to address them. For instance, if a gap identified is the lack of efficient utility systems, the hospital will require financial expenses to ensure they are in good condition to avoid putting patients at risk of harm when they malfunction. It is also important to consider the costs that an organization can incur to maintain accreditation status. For the Joint Commission, a health organization is required to pay $46,000 annually to keep the accreditation. This can be costly to particular organizations, especially if they had not budgeted for the fee. There are many benefits of conducting voluntary accreditation, and they outweigh the costs. One significant benefit of meeting accreditation requirements is that the quality of services in the hospital will improve. According to the CDC (2021), 95% of health departments that received accreditation agreed that it stimulated the quality of services they offered. Accreditation requirements ensure that there are numerous changes in the health care institution to address gaps. For instance, the hospital can take action on incompetent health staff by terminating their jobs and hiring competent workers, ensuring that the quality of patient care is enhanced and that there is better compliance with regulations and standards. Another benefit is that accreditation helps improve accountability and transparency. According to the CDC (2021), 89% of accredited health departments concluded that health care accreditation helped improve accountability and transparency. Meeting the official certification requirements needs a lot of accountability from all stakeholders in the health organization. For instance, hospitals leaders ensure transparency by communicating the plans and procedures needed to be taken to reach accreditation standards. Stakeholders must be accountable for any mistakes for them to be addressed and report incidences that may hinder certification. Another benefit of accreditation is that it strengthens the utilization of resources. With resources required to improve the organization’s standards, the hospital leaders ensure they are used efficiently and that there are no wastages. According to the CDC (2021), 68% of health care organizations with accreditation stated that the certification process strengthened their utilization of resources. By identifying priorities that need to be addressed, the institution can focus its resources on the issues before using the resource to cater to other needs. Finally, meeting accreditation requirements improves patient safety and care, resulting in reduced risk and liability for the health organization (The Joint Commission, 2022). Incidences of medication errors, patient breaches, and upcoding fraud can adversely affect the running of a hospital since ot may incur many costs in legal battles. However, when patient safety and care are enhanced, the incidences can be avoided, saving the health organization a lot of money.
References OSHA (n.d.). Safety and Health Management Systems and Joint Commission Standards. https://professorhelps.com/category/assignment-writing-help/ Accreditation Commission for Health Care. (2022). About ACHC accreditation. About Accreditation – ACHC Wadhwa, R., & Huynh, A. P. (2021). The Joint Commission. In StatPearls. StatPearls Publishing. Moore, W., & Frye, S. (2020). Review of HIPAA, Part 2: Limitations, rights, violations, and role for the imaging technologist. Journal of Nuclear Medicine Technology, 48(1), 17–23. https://nursingexpertwriters.com/ The Joint Commission. (2022). Implement standards to improve care. Our Standards for Hospital Accreditation | The Joint Commission CDC. (2021). Benefits and impacts of accreditation. CDC – Benefits and Impacts of Accreditation – Health Department Accreditation – STLT Gateway Moore, W., & Frye, S. (2019). Review of HIPAA, Part 1: History, protected health information, and privacy and security rules. Journal of Nuclear Medicine Technology, 47(4), 269–272. https://onlyprofessors.com/tag/writing/
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Case Study: Stage 4 of The Transtheoretical Model of Change
Individual behavior change is facilitated by the Transtheoretical Model of Change, which contributes to improved health outcomes. Individuals can be guided through the stages of the Transtheoretical Model of Change by utilizing a variety of strategies and techniques. As highlighted by Liu et al., individuals are more likely to alter their behavior if they believe the advantages to outweigh the disadvantages (2018). In this aspect, the prospective benefits of adopting a new behavior are the motivating factor. This discovery implies that Motivational Interviewing approaches are suitable for guiding patients through the Transtheoretical Model of Change. In Rebecca’s example, Motivational Interviewing techniques can assist her in moving from the Change Model’s Preparation stage to the Action stage. This paper describes how, as Rebecca’s primary nurse, I would implement Motivational Interviewing strategies to impact the relevant parts of the Transtheoretical Model of Change. In addition, the nursing essay help work describes the behaviors Rebecca would need to engage in, the strategies I should avoid as her primary nurse, and the discharge planning strategy.
Implementation of Motivational Interviewing Methods
Rebecca may be able to move to the Action stage of the Transtheoretical Model of Change by utilizing Motivational Interviewing (MI) approaches. To achieve behavioral change, the model incorporates a dynamic exchange between several elements, including the stage of change. In addition to the stages of change, Liu et al. (2018) identified self-efficacy, decisional equilibrium, and change processes as additional aspects. These factors affect progression through the stages. Regarding Rebecca, I would employ MI tactics by targeting these elements.
Rebecca’s self-efficacy would be improved by utilizing MI approaches. Self-efficacy, as defined by Liu et al. (2018), refers to the patient’s belief in their own capacity to plan and execute the actions required to attain desired goals. Rebecca asserts that while she is willing to change, she lacks the ability to do so. Because they are mostly patient-centered, MI methods can boost self-efficacy (Mojahed & Navidian, 2018). Improving Rebecca’s self-efficacy would encourage her to play a more active and central role in adopting the change and advance her to the Action stage.
Rebecca would be educated on the merits and cons of taking action to enhance her health as the majority of the MI techniques aimed at this component. Rebecca is likely to take action to enhance her health if the perceived advantages outweigh the perceived negative effects, according to the principle of decisional balance. The patient acknowledges that she is unable to alter her present eating habits, which are contributing to her bad health. As a result, the application of the decisional equilibrium component of the change model would serve as the major source of motivation. Rebecca would be informed of the pros and cons of taking action to improve her health using MI approaches. Buy essay help to get top papers written by experts.
Rebecca would be able to comprehend the proper change procedures and advance to the Action phase with the aid of MI approaches. Rebecca claims she has no idea how to alter her behavior. Liu et al. (2018) argued that the processes of change involve approaches that utilize the mechanisms of cognition and behavior to modify experience and the surrounding environment to modify behavior. Therefore, I would employ MI approaches to enhance Rebecca’s comprehension of these processes and encourage her to take action. The MI approaches would address a variety of pertinent topics, including goal-setting and self-monitoring.
Rebecca Will Need to Engage in New Behaviors
Rebecca is obese; hence, the three most important categories of behaviors she must engage in to be successful and obtain better health outcomes are healthy eating, physical activity, and health literacy. While healthy eating and physical activity are required behavioral changes for the effective treatment of obesity in adults, as noted by Raynor and Champagne (2016), health literacy is also essential because it would enable Rebecca to remain committed to achieving better health even after the one-week period with her primary nurse concludes.
Nutrition and Physical Activity
Given their ability to improve health outcomes for individuals with obesity, dietary adjustments would be a crucial behavioral modification for Rebecca. Rebecca indicates that she constantly consumes unhealthy meals and frequently eats out of sadness. Likewise, Rebecca would need to engage in physical activity to improve her health. She is worried because she believes her legs can no longer support her weight. This issue underscores the reality that, similar to the adoption of good eating, her adoption of physical exercise would be influenced by multiple circumstances. Rebecca would be able to identify these aspects and comprehend their consequences for dietary and physical activity modifications with the use of MI. According to Sharkey et al. (2020), the most effective food and physical activity improvements include instructional aspects, active involvement, and supportive features. Motivational interviewing is an element of support. In this approach, the specific exercises and diet would be determined in collaboration with the patient. This method would center the behavior on the patient.
Rebecca will only be on the ward for one week, hence the role of behavior modification involving health literacy is tied to this. Rebecca emphasizes that she lacks fundamental understanding on how to handle her condition. Michou et al. (2018) say that research indicates a correlation between low health literacy and the development of obesity; therefore, Rebecca can achieve successful change and better health outcomes by accessing current health information. The modification would facilitate her acceptance of dietary and physical activity modifications. Knowledge of mHealth and telehealth apps, for instance, would enable her to benefit from supportive technologies, which have the potential to improve health interventions (Batsis et al., 2019). Rebecca’s adoption of self-care would be aided by a shift in behavior involving improved health literacy.
Techniques to Avoid
Stigmatization and energy-restricted diet prescriptions are techniques to avoid using with Rebecca, as they may have harmful effects and outcomes. Pervasive but unsubstantiated is the notion that shame associated with obesity could inspire individuals to adopt better behaviors (Puhl & Heuer, 2010; Petrin et al., 2017). Rebecca’s phrase choice indicates that she is aware of the stigma associated with obesity and has likely internalized it. For instance, she uses the term “skinnier” to signify a better lifestyle. Consequently, adopting stigmatization as a tactic to inspire her to advance to the Action stage is likely to result in negative effects and outcomes. As noticed by Dayan et al., prescribing energy-restricted diets should also be avoided because they are unsuccessful at promoting long-term weight loss and may predispose Rebecca to weight gain (2019). Appropriate would be the use of unbiased attitudes toward obesity in lieu of stigma and behavioral modification in lieu of energy-restricted diets.
According to Doenges et al., the discharge planning would be based on three nursing priorities (2019, p. 434). The first nursing goal would be to support Rebecca in identifying a suitable weight management program that incorporates healthy food and physical activity. The second priority would be to foster a positive self-image. The third nursing aim would be to urge her to adopt a healthy lifestyle so that she can maintain her weight throughout her life. The following items would comprise the discharge objectives:
1. dietary habits promoting health are identified
Identifying appropriate physical activity patterns
3. A future-oriented (long-term) weight control behavior plan is designed
The identification of cognitive behavioral treatment help to improve self-image and prevent relapse. Cognitive-behavioral therapy can help Rebecca acquire the necessary support for behavior modification. According to Foreyt and Johnston (2016), this type of therapy can strengthen self-monitoring, promote positive self-image, improve stress management, offer social support, and prevent relapse.
5. A strategy to address needs following discharge. Such needs include post-operative care at home.
Motivational Interviewing techniques would be effective for influencing the essential components of the Transtheoretical Model of Change in order to assist Rebecca in adopting a new behavior with improved health outcomes. As the primary nurse, I would utilize Motivational Interviewing strategies to increase Rebecca’s self-efficacy, support her decisional balance, and improve her processes of change in order for her to effectively advance to the Action stage. Rebecca would need to engage in behaviors such as good diet, physical activity, and health literacy improvement. As her primary nurse, I would avoid practices such as stigmatization and energy-restricted diet prescriptions. I would organize discharge planning with several essential objectives in mind. The objectives include identifying healthy eating and physical activity routines, building a long-term strategy for weight control, identifying cognitive behavioral assistance, and establishing a plan to fulfill her requirements beyond discharge.
Batsis, J. A., Naslund, J. A., Zagaria, A. B., Kotz, D., Dokko, R., Bartels, S. J., & Carpenter-Song, E. (2019). Technology for behavioral change in rural older adults with obesity. Journal of nutrition in gerontology and geriatrics, 38(2), 130-148.
Dayan, P. H., Sforzo, G., Boisseau, N., Pereira-Lancha, L. O., & Lancha Jr, A. H. (2019). A new clinical perspective: Treating obesity with nutritional coaching versus energy-restricted diets. Nutrition, 60, 147-151. https://onlyprofessors.com/tag/buy-essay-help/
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span. FA Davis.
Foreyt, J. P., & Johnston, C. A. (2016). Behavior modification and cognitive therapy. In Lifestyle Medicine (pp. 129-134). Springer, Cham.
Liu, K. T., Kueh, Y. C., Arifin, W. N., Kim, Y., & Kuan, G. (2018). Application of transtheoretical model on behavioral changes, and amount of physical activity among university’s students. Frontiers in psychology, 9, 2402.
Michou, M., Panagiotakos, D. B., & Costarelli, V. (2018). Low health literacy and excess body weight: A systematic review. Central European journal of public health, 26(3), 234-241.
Mojahed, K., & Navidian, A. (2018). The effect of motivational interviewing on self-efficacy to quit hookah smoking in pregnant women. Journal of hayat, 24(1), 84-96.
Petrin, C., Kahan, S., Turner, M., Gallagher, C., & Dietz, W. H. (2017). Current attitudes and practices of obesity counselling by health care providers. Obesity research & clinical practice, 11(3), 352-359.
Puhl, R. M., & Heuer, C. A. (2010). Obesity stigma: important considerations for public health. American journal of public health, 100(6), 1019-1028.
Raynor, H. A., & Champagne, C. M. (2016). Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults. Journal of the Academy of Nutrition and Dietetics, 116(1), 129-147.
Sharkey, T., Whatnall, M. C., Hutchesson, M. J., Haslam, R. L., Bezzina, A., Collins, C. E., & Ashton, L. M. (2020). Effectiveness of gender-targeted versus gender-neutral interventions aimed at improving dietary intake, physical activity and/or overweight/obesity in young adults (aged 17–35 years): a systematic review and meta-analysis. Nutrition journal, 19(1), 1-20.